Structured Notes for Care Providers

Structured Notes Objective Describe the key features of a structured note. Describe how to set default preferences. Identify which data will auto-populate versus manual entry. Describe how to create an acronym expansion. Identify how to assign for a co-signature.

Advantages of Notes in QUEST Increased efficiency: Use of ‘copy forward’ like functionality Pulling data from other sources, e.g. VS, labs, meds, health issues Drives compliance with key indicators – i.e. device medical necessity Accessible anywhere by all providers Standardizes billing and compliance language requirements

Examples of Structured Notes Physician: Allied Health: H&P Event Note Progress Note Procedure – Central Line Discharge Note Ambulatory Notes Amb H&P Amb Well Child Amb End of Visit Amb Follow Up Allied Health: Case Management Note Clinical Social Work Note ED Rapid Screening Exam Procedure – PICC Insertion Patient Profile Respiratory Care Note Spiritual Care Note Ambulatory Notes Amb Intake Note Amb Triage Note

Navigating Tools To navigate through the content, there will be 3 navigational buttons located on the bottom left corner of the screen. = to return to the previous slide = to advance to the next slide = to return to the Table of Contents

Table of Contents Use the navigation button below or click a topic to proceed. How to Enter a Note Creating a Preferred Documents List Basic Functionality How to Manage/Modify Pulling Data Into the Note Modifying Template “My Default” Exam Acronym Expansion Use of Health Issues within the Note Adding a Co-Signer Changing a Co-Signer Attending Attestation Unfinalizing a Note Conclusion

Structured Notes: How to Enter a Note To access a structured note, first select a patient and then click Enter Document icon.

Structured Notes: How to Enter a Note Type the first few letters of the document name to begin the search (no need to hit <Enter>).

How to Enter a Note Once found, highlight the note and click . Structured Notes: How to Enter a Note Once found, highlight the note and click .

Creating a Preferred Documents List Structured Notes: Creating a Preferred Documents List Notes frequently used can be saved as a list of “personal documents.”

Creating a Preferred Documents List Structured Notes: Creating a Preferred Documents List To create your list of Personal Documents: Select a patient. Select the Preferences Menu. Select Document Entry…

Creating a Preferred Documents List Structured Notes: Creating a Preferred Documents List To create your list of Personal Documents: (cont.) Click the to open each section Highlight your note and click

Creating a Preferred Documents List Structured Notes: Creating a Preferred Documents List To create your list of Personal Documents: (cont.) Now, go to the Browse Start Point tab Select Personal Documents Click Set As Default

Creating a Preferred Documents List Structured Notes: Creating a Preferred Documents List By setting Personal Documents as your default, Enter Document icon will always launch to your default view.

Structured Notes: Basic Functionality All structured notes have the same basic functionality: BLUE exclamation points ( ! ) are required fields to “complete” a note. RED asterisks (*) are mandatory fields to “save” a note. Multiple check boxes ( ) can be selected, but only one radio button ( ) can be selected per section.

Structured Notes: Basic Functionality To remove a selected radio button ( ), right-click and select Delete Data. If an option with an ellipse (…) is selected, additional data fields will appear.

Structured Notes: Basic Functionality Use the navigation buttons to move between document sections, when available. or navigates to the next or previous section. or navigates to the first or last section of the structured note.

Structured Notes: Basic Functionality Another way of navigating within the note is to hover the mouse over the Sections tab, located at the top-left corner. Click the and select the specific section you would like to view.

Structured Notes: Basic Functionality Most structured notes have the current Date and Time auto populate upon opening. Make sure your name appears in the Accessing Provider field.

How to Manage / Modify Structured Notes: Structured notes have a 20 minute lock-out feature to prevent concurrent charting. There is a potential to lose unsaved data beyond this time. When all “required” and “mandatory” fields are filled, the note can be saved as complete or final. Notes that require a co-signature can only be saved as incomplete. Once the note is co-signed, it can be saved as final.

How to Manage / Modify Structured Notes: Whenever given the option, Submit as Final is the preferred method of saving. Final Documents cannot be modified. Free Text notations may be added using the “Append” function.

How to Manage / Modify Edit saved notes within the Documents tab Structured Notes: How to Manage / Modify Edit saved notes within the Documents tab First, highlight the note. Then right-click. Modify Document – to edit a complete or incomplete note. Cancel Document – to delete a note entered in error. This will display as a lined out item and cannot be reinstated. Append Document – to add documentation to a finalized note.

Pulling Data Into the Note Structured Notes: Pulling Data Into the Note The Preview tab is to view the note in its entirety. The Preview option displays in real time, which can be used to review the note during documentation and prior to saving.

Pulling Data Into the Note Structured Notes: Pulling Data Into the Note Notes may contain “pull sets” that retrieve data from other applications. Only selected checkboxes of a “pull set” will populate the note. Below is an example of a “pull set.”

Pulling Data Into the Note Structured Notes: Pulling Data Into the Note If pull set data need to be changed, use the application icons (examples below) to update the patient information while in the note. Otherwise, erroneous data will always exist.

Pulling Data Into the Note Structured Notes: Pulling Data Into the Note If needed, click the Refresh icon to populate the pull set with the updated information.

Pulling Data Into the Note Structured Notes: Pulling Data Into the Note Notes may also have medical logic modules (MLMs) that allow data to populate your note. An example is lab results. Some MLM text fields will allow for information to be added or deleted.

Pulling Data Into the Note Structured Notes: Pulling Data Into the Note Some MLMs are on-demand options. Select the radio button Check mark the info to populate the note Click OK

Structured Notes: Modifying Template Notes may provide options for documentation preference. An example is shown below: Physical exam by individualized systems (default) Physical exam (free text)

Structured Notes: Modifying Template Before documenting on the note, select Modify Template. The template can only be modified when data do not exist in the section that will be modified.

Structured Notes: Modifying Template Choose your documentation preference and deselect the other: Physical exam by individualized systems (available as default) Physical exam by all systems (free text)

Structured Notes: Modifying Template After making your choice, check mark Save template for me and then click OK. This recalls your setting every time you open the note, regardless of the selected patient.

“My Default” Exam Structured Notes: When the option Save as Default is available, create your default information first. Fill out each text field for that section. Then save it as your default. Physical exam by individualized systems Physical exam by all systems (free text)

“My Default” Exam Structured Notes: SUGGESTION: Retrieve your “default exam” or “my last exam for patient” before entering any free text. Otherwise, the free text will be overwritten. Physical exam by individualized systems Physical exam by all systems (free text)

Structured Notes: Acronym Expansion Because structured notes have text fields, using Acronym Expansion can be helpful. To setup your acronyms, select Preferences > Acronym Expansion.

Structured Notes: Acronym Expansion Click Add to create your own acronym or click Import From Other User.

Acronym Expansion In the Acronym field, type an acronym. Structured Notes: Acronym Expansion In the Acronym field, type an acronym. It is suggested to begin some acronyms with a period (.) to prevent unintentional acronym expansion. In the Expanded Text field, type the full text of the acronym. Click Apply to create more acronyms.

Structured Notes: Acronym Expansion When importing from another user, use the dropdown list or type a person’s last name.

Structured Notes: Acronym Expansion Place a checkmark next to the acronyms you would like to import and then click OK.

Structured Notes: Acronym Expansion REMINDER: Acronym expansion is case sensitive. For example, “bid” will not expand to “twice a day” because the acronym is in caps.

Use of Health Issues within the Note Structured Notes: Use of Health Issues within the Note Health Issues management can be done from within a note by clicking the Health Issues icon.

Use of Health Issues within the Note Structured Notes: Use of Health Issues within the Note Drag and drop the order/medication on top of a health issue in the Problem List.

Use of Health Issues within the Note Structured Notes: Use of Health Issues within the Note The order/medication will not associate if dropped in a blank area. Blank Area

Use of Health Issues within the Note Structured Notes: Use of Health Issues within the Note Check mark Include Linked in order to associate an order/medication to multiple health issues.

Use of Health Issues within the Note Structured Notes: Use of Health Issues within the Note Single click in the text box to document your Assessment and Plan for each Health Issue.

Use of Health Issues within the Note Structured Notes: Use of Health Issues within the Note To take out data entered in error, remove the check mark.

Adding a Co-Signer To assign a note for co-signature: Structured Notes: Adding a Co-Signer To assign a note for co-signature: Select the Document Info tab Then check mark the Co-Signer checkbox

Structured Notes: Adding a Co-Signer Select the co-signer’s name from the list of available current providers.

Adding a Co-Signer Structured Notes: If the co-signer’s name is not listed: Delete the name in the Care Provider field. Type the co-signer’s name. Click Search. If multiple names appear, select the correct name. TYPE NAME HERE

Structured Notes: Changing a Co-Signer If the designated co-signer needs to be corrected, it can be changed using Signature Manager. If the icon is not readily available, you can use the menu option Go To > Enter/View > Signature Manager.

Changing a Co-Signer Structured Notes: To change the co-signer through Signature Manager: Change Provider Selection to Selected Providers. Click the ellipsis (…) to search for the co-signer’s name who was identified in error. Narrow the Item Type Filter to “documents” only. Select Reassign. Click Get List.

Changing a Co-Signer Structured Notes: To change the co-signer through Signature Manager (cont.): Check mark the note that needs to be re-assigned. Click Reassign.

Changing a Co-Signer Structured Notes: To change the co-signer through Signature Manager (cont.): Click the ellipsis to search for the correct co-signer. Enter the reason for re-assigning to a new co-signer. Click OK.

Attending Attestation Structured Notes: Attending Attestation Billing Service Level and Attending Attestation sections of a note are for Attending use only.

Attending Attestation Structured Notes: Attending Attestation The Attending Evaluation Date/Time is a manual entry for when the Attending does the attestation.

Attending Attestation Structured Notes: Attending Attestation Attending Attestation: Provide Attending attestation statements for different scenarios; additional comments as appropriate.

Attending Attestation Structured Notes: Attending Attestation When the Attending is ready to finalize the note, select Note Finalization. Once finalized, the note cannot be modified.

Structured Notes: Unfinalizing a Note In the event a note was finalized in error, only the Attending can unfinalize that note. Notes can be unfinalized on “active” visit accounts only. Visit accounts are no longer active after 14 days post discharge.

Unfinalizing a Note To “unfinalize” a note: Structured Notes: Highlight/Select the note Right-click Select Unfinalize Document

Unfinalizing a Note To “unfinalize” a note (cont.): Structured Notes: Answer the prompt. Then right-click again on the note to modify.

Structured Notes: Unfinalizing a Note When re-finalizing the note, notice that Note Finalization is already marked. You must uncheck Incomplete in order to save and finalize.

Structured Notes: Conclusion For issues with a structured note, contact the Help Desk at (714) 456-3333.

Conclusion You have reviewed: The functionality of a Structured Note. Structured Notes: Conclusion You have reviewed: The functionality of a Structured Note. How to create acronym expansions. How to designate a co-signer. How to modify your template. How to set your default preferences. How to re-assign to the correct co-signer.

You have completed the course. Structured Notes: Conclusion You have completed the course. DISCOVER ● TEACH ● HEAL